This descriptive study extends the literature on EBPT implementation by providing insight into potential service-level influences on the implementation of cognitive therapy. In contrast to previous work in this area, which has been conducted in children’s mental health services, private practice settings, or on inpatient units, this research provides a detailed understanding of both the social context and the perspectives of outpatient service providers who work with adults in a large, public mental health system. Further, it illustrates an initial formative assessment designed to inform the development of a training and implementation program that is responsive to potential influences on implementation (Stirman et al. 2010
). While there are few such examples of the use of this strategy in the mental health literature, formative research is critical to the development of appropriate implementation and facilitation strategies (Stetler et al. 2006a
). Two findings in particular increase insight into agency dynamics and clinician perceptions that might influence implementation if not addressed. Clinicians generally expressed very positive attitudes towards training in CT regardless of their organizational context, but asserted that if trained in CT, they would selectively implement elements of CT rather than attempting to deliver the full protocol. Additionally, clinicians and administrators described specific patterns of response to change that have the potential to undermine the implementation of an EBPT.
Clinicians’ intention to selectively implement CT has potential implications for the level of treatment fidelity that can be expected after training. Clinicians anticipated that comfort with previously learned interventions, the effort required to implement CT, specific client needs and characteristics, and concerns about autonomy may drive their decisions to implement CT. Selective implementation of interventions without a sound case conceptualization could lead to less optimal outcomes (Henggeler 2004
), which could in turn reinforce clinicians’ concerns about CT’s applicability to certain patient populations. While they believed CT could be helpful to at least some of their clients, concerns about CT’s fit with the needs and presenting problems of their clients were consistent with previous findings (Aarons and Palinkas 2007
). Notably, the perception held by some clinicians that CT is only effective for present-focused, discrete symptoms or problems, conflicts with empirical evidence that cognitive therapies can be used effectively with individuals with severe mental illness (Grant et al. 2011
), those who experienced trauma (Ehlers et al. 2003
; Resick et al. 2008
), and those with personality disorders and other challenging presentations (Davidson et al. 2006
; Lam et al. 2003
). These findings highlight the importance of providing clinicians and administrators with salient evidence regarding the applicability of CT to their clientele as they make decisions about initial adoption. In addition to empirical data for specific disorders, or combinations of disorders, presenting highly relevant case material or demonstrations can allow clinicians and administrators to evaluate the applicability of CT to their consumers.
Taken together, these findings support the need for ongoing consultation after introductory training (Beidas and Kendall 2010
; Rakovshik and McManus 2010
). Consultation is necessary to provide support after didactic training, as clinicians attempt to develop skills (Herschell et al. 2010
; Miller et al. 2004
; Sholomskas et al. 2005
). In the context of consultation, the opportunity to deliver a new treatment and receive guidance may impact clinicians’ treatment preferences. Skeptical clinicians may need to discuss their concerns and receive feedback from consultants as they attempt to deliver CT. Once trained to competency and given the opportunity to evaluate their own experiences with CT (Aarons and Palinkas 2007
; Rycroft-Malone et al. 2004
), clinicians may be more willing and able to deliver it at adequate levels of fidelity. Although some clinicians expressed concern about the implications of CT training on their autonomy, there is also evidence that ongoing fidelity monitoring and support in the form of supportive consultation can improve the quality of implementation and reduce turnover (Aarons et al. 2009
Training consultants who provide CT to client populations that are similar to the agency’s typical consumers can ensure that training is relevant to clinician and consumer needs (Riggs et al. 2012
). Selection of training cases that provide opportunities for consultation on challenging issues can further engage clinicians (Stirman et al. 2010
). In light of the heterogeneous populations served by community mental health systems, some adaptation may be necessary, and may ultimately improve the likelihood that the treatment will be sustained. Emerging findings confirm that during implementation, EBPTs are often modified in response to client or organizational needs (Lundgren et al. 2011
). In some cases, cognitive behavioral therapies can be implemented flexibly without a detrimental impact on treatment outcomes (DeRubeis et al. 2005
; Levitt et al. 2007
). Thus, training and implementation programs should be designed to support clinicians’ ability to flexibly deliver CT or integrate it with other EBPTs for severe mental illness or co-occurring problems (Turkington et al. 2006
) without compromising quality or moving beyond the evidence base. Further, consultation can include facilitative strategies to address barriers to implementation (Stirman et al. 2010
Our findings revealed some contextual factors that have the potential to influence early adoption and subsequent implementation of CT or other EBPTs. Clinicians in the agencies with the worst climate and culture profiles endorsed reactions to change that were markedly more negative than those in other contexts. In light of the high workloads, scant recognition, and lack of personal connection with clients that were evident in both qualitative and quantitative data, some clinicians and administrators described cynicism or even hostility about change. In such contexts, clinicians may not commit to learning or using a new treatment if it is viewed as a temporary priority for the administration or a mandate that requires additional work with no support or recognition. Consistent with previous findings, clinicians in these agencies also indicated that they may not have time to participate in early preliminary consultation or ongoing EBPT support, both of which are increasingly recognized as critical to implementation and sustainability (Aarons et al. 2011
; Beidas and Kendall 2010
). Although all agencies in our sample were part of a publicly-funded system and clinicians described challenges meeting their paperwork requirements and agency productivity demands, these were only viewed as potential implementation barriers in the “worst” climates and cultures.
Facilitative strategies to address such barriers during CT training programs have been shown to be more effective than training alone (Kauth et al. 2010
). A number of integrated and complementary strategies may be necessary, and facilitators should work with stakeholders to adopt a multi-level approach to effect change. At the system or payer level, reimbursement for lost productivity or higher reimbursement rates for CT-trained clinicians would convey support at high levels within the mental health system and make intensive training financially feasible for agencies. Although initially costly to the system, emerging evidence suggests that EBPT implementation can lead to cost-savings (Kilmer et al. 2011
), particularly in integrated healthcare systems or networks in which clients tend to remain enrolled over the long-term. Given the critical role of leadership in the success of implementation efforts, management support and follow-through should be facilitated as part of an implementation program (Aarons 2006
; Kauth et al. 2010
). Findings on reactions to change suggest that facilitators should encourage the inclusion of clinicians in decision-making about EBPT implementation from the start. Clinician and administrator input regarding scheduling, feasible consultation formats, preparation activities, and strategies to mitigate workload and productivity demands during training can also increase the likelihood of success. Facilitators could also work with clinicians and administrators to develop streamlined templates for documentation that include checklists or prompts to document important treatment elements. While these strategies may be successful in some agencies, in settings with poorer organizational contexts, successful implementation may not be possible without more intensive organization-level intervention (Glisson et al. 2010
; Hemmelgarn et al. 2006
Some limitations to this study are important to note. We attempted to minimize the potential for common method bias (Podsakoff et al. 2003
) by using a number of procedural remedies including temporal, methodological, and proximal separation of interview and survey collection, protecting respondent anonymity, attempting to reduce evaluation apprehension, and aggregating the survey scores rather than using individual-level data. However, we were not able to mitigate all potential sources of common method biases. It is also possible that our recruitment strategy resulted in a sample of clinicians with more extreme opinions about CT. An additional limitation is that most clinicians had relatively limited exposure to CT prior to the interviews. Clinician attitudes towards CT and their views on barriers to adopting CT might well be different after a higher level of exposure (e.g., training and consultation), and we are examining this possibility in ongoing research. However, for this study, we did not collect data on whether study participants subsequently received CT training. Thus, we are unable to draw conclusions about the influence of contextual factors and attitudes on subsequent training in, or use of, CT. In this project, our interest was in the types of service-level attitudes and barriers that occur early in the implementation process because such barriers, if not addressed, could undermine progress towards a more intensive phase of implementation. We also did not collect information on treatment outcomes, which ultimately is of interest in evaluating the success of the implementation of an EBPT.
Although our sample consisted of a relatively small group of public-sector clinicians in one urban setting and the sample size precluded hypothesis testing or additional exploration of survey data, our study provides a unique synthesis of data regarding perceptions of evidence and context in mental health. This study provides a nuanced view of the barriers that clinicians and administrators in different organizational social contexts perceive to be present at the provider, organization, and to some extent, the broader system level. These findings have implications for the development of facilitation strategies that are relevant to public mental health system administrators, clinicians, and investigators interested in promoting access to EBPTs such as CT. EBPT training programs should be designed with sensitivity to clinician concerns about the fit of the treatment with their own therapeutic practices, their questions about its applicability to the population they serve, and the contextual factors that may impact long term success. Further study of factors such as clinician experiences, attitudes, and perceptions of barriers throughout the course of training and implementation can shed light on whether and how they impact outcomes of interest (Palinkas et al. 2008
). Training and implementation programs will benefit from additional formative research on factors that may influence their success, as well as more research on interventions to facilitate implementation of specific EBPTs.